Can a patient with C. difficile infection be removed from isolation before completing a 10-day course of vancomycin (Vancomycin hydrochloride)?

From the Guidelines

The patient with C. difficile infection can be removed from isolation before completing the full 10-day course of vancomycin hydrochloride, provided they have been clinically improved with no diarrhea for at least 48 hours. The decision to discontinue isolation should be based on symptom resolution rather than completion of antibiotic therapy. Specifically, once the patient has formed stools and has had fewer than 3 bowel movements in a 24-hour period, they are generally considered non-infectious. This approach is reasonable because C. difficile transmission primarily occurs through the fecal-oral route, and the risk of spreading the infection significantly decreases when diarrhea resolves 1. Some key points to consider when deciding to remove a patient from isolation include:

• Clinical improvement, as evidenced by formed stools and fewer than 3 bowel movements in a 24-hour period
• The importance of good hand hygiene with soap and water, as C. difficile spores can persist on surfaces and are not effectively killed by alcohol-based sanitizers 1
• The need for continued environmental cleaning protocols in the patient's room, even after isolation is discontinued, using specific cleaning agents like chlorine-based products 1 It is also worth noting that the 2021 clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) provides recommendations for the treatment of Clostridioides difficile infection in adults, but does not specifically address the issue of isolation duration 1. However, the guideline does emphasize the importance of prompt and precise diagnosis, as well as the use of contact precautions and good hand hygiene to prevent the spread of C. difficile 1. In this case, since the patient has had 1 soft, formed bowel movement daily for the past 2 days, and has been on vancomycin for 4 days, it is likely that they can be safely removed from isolation, as long as good hand hygiene and environmental cleaning protocols are continued.

From the FDA Drug Label

In two trials, Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with C. difficile-associated diarrhea (CDAD)

The patient should complete the 10-day course of antibiotics before being removed from isolation. This is because the drug label specifies that vancomycin hydrochloride capsules were evaluated for 10 days in clinical trials for the treatment of C. difficile-associated diarrhea.

• Key consideration: The duration of treatment is crucial in ensuring the resolution of diarrhea and preventing recurrence.
• Clinical decision: It is essential to prioritize the completion of the full treatment course to minimize the risk of recurrence and ensure the patient's safety and the safety of others. 2 2

From the Research

Patient Isolation for C. difficile Infection

The patient in question has been diagnosed with C. difficile infection and is currently undergoing a 10-day course of vancomycin. The nurse supervisor is inquiring about the possibility of removing the patient from isolation due to high patient volume.

Current Treatment and Isolation Status

• The patient is on day 4 of a 10-day course of vancomycin 3, 4.
• The patient has shown improvement with 1 soft, formed bowel movement daily for the past 2 days.
• The patient is currently in a single room isolation with gown, gloves, and hand washing with soap and water.

Recommendations for Isolation Removal

• According to the studies, vancomycin therapy should be continued for 10 days or more in patients with severe disease to eradicate the responsible organism 3.
• There is no evidence to suggest that removing the patient from isolation before completing the 10-day course of vancomycin is recommended 4, 5.
• In fact, one study suggests that vancomycin alters the gut microbiota and does not permanently clear C. difficile, which may lead to recurrence or transmission 6.

Conclusion Not Permitted, Only Actionable Items

• Complete the 10-day course of antibiotics and then remove the patient from isolation, as this is the recommended treatment duration for C. difficile infection 3, 4, 7.
• Recheck C. difficile toxin after completion of the treatment course to confirm eradication of the infection, but this is not a prerequisite for removing the patient from isolation 3, 4.
• Removing the patient from contact isolation before completing the treatment course is not recommended, as it may increase the risk of transmission to other patients 5, 6.